D221 Final Paper: Practice Improvement Plan for Pressure Injury Prevention

Student Name

Western Governors University 

D221 Organizational Systems and Healthcare Transformation

Prof. Name

Date

Situation (S)

Healthcare-Related Situation

The prevention of pressure injuries among immobile hospitalized patients remains a fundamental responsibility of nursing practice and a critical indicator of patient safety. Patients who are unable to reposition independently are particularly vulnerable to sustained pressure on bony prominences, which compromises tissue perfusion and leads to skin breakdown. When structured and evidence-based turning protocols are absent or inconsistently applied, the likelihood of hospital-acquired pressure injuries (HAPIs) increases significantly. These injuries contribute to patient discomfort, elevate the risk of infection, prolong hospital stays, and complicate discharge planning. From an organizational perspective, unmanaged pressure injuries result in avoidable costs, inefficient use of clinical resources, and higher rates of hospital readmission, ultimately undermining care quality and operational effectiveness.

Background (B)

A2a: Data

Hospital-acquired pressure injuries are widely recognized as a benchmark for evaluating the quality of nursing care within healthcare systems in the United States. Research indicates that more than 2.5 million individuals develop pressure injuries annually, leading to increased morbidity, prolonged recovery, and substantial healthcare expenditures (Tervo-Heikkinen et al., 2023). In response to this widespread issue, the Agency for Healthcare Research and Quality (AHRQ) introduced the Pressure Injury Prevention Toolkit to support healthcare organizations in adopting standardized prevention strategies. The toolkit promotes interdisciplinary collaboration, routine skin assessments, scheduled repositioning, and staff education as core preventive measures. When consistently implemented, these evidence-based practices reduce injury prevalence, enhance patient safety, and support optimal healing outcomes.

A2b: Patient Safety Standards

Pressure injury prevention is explicitly addressed within The Joint Commission’s National Patient Safety Goal (NPSG.14.01.01), underscoring its importance as a national patient safety priority. Compliance with these standards requires early identification of at-risk patients using validated tools such as the Braden Scale. Preventive interventions include maintaining skin hygiene, reducing friction and shear forces, ensuring adequate nutrition and hydration, and adhering to scheduled turning protocols. By aligning clinical practice with these standards, healthcare professionals can proactively mitigate risk, preserve skin integrity, and deliver care that meets established benchmarks for safety and quality.

Assess (A)

A3: Impact

Pressure injuries impose a considerable financial and operational burden on healthcare organizations. The treatment of advanced wounds often necessitates costly interventions, including specialized dressings, pressure-relieving surfaces, prolonged nursing care, and antimicrobial therapy. Beyond direct costs, pressure injuries negatively affect patient satisfaction scores and publicly reported quality metrics. Additionally, the increased workload associated with wound management contributes to nurse fatigue, emotional stress, and reduced job satisfaction, which can exacerbate staffing challenges and compromise overall organizational performance.

A3a: Value

Implementing effective pressure injury prevention strategies yields substantial benefits for both patients and healthcare systems. Patients experience improved comfort, reduced pain, and faster recovery trajectories. From an operational standpoint, prevention minimizes documentation burdens, decreases treatment-related costs, and allows nurses to allocate more time to other critical patient care activities. Moreover, prioritizing preventive care reflects a commitment to patient-centered practice and ethical nursing responsibilities, reinforcing professional accountability and clinical excellence.

Evidence-Based Practice Change

A4a: High-Reliability Organization

The adoption of a standardized pressure injury prevention protocol aligns with the principles of a high-reliability organization (HRO), which emphasizes consistency, vigilance, and proactive risk mitigation. HROs aim to reduce variability in care delivery and anticipate potential failures before patient harm occurs (Khan & Jonusas, 2019). Evidence supports repositioning immobile patients at least every two hours as an effective strategy for reducing pressure injury incidence. Standardizing this practice across units, supported by validated risk assessment tools, promotes equitable care delivery and fosters a culture of safety consistent with AHRQ and Joint Commission recommendations.

A4b: Barriers

Despite strong evidence supporting turning protocols, implementation challenges persist. Common barriers include staffing constraints that disrupt scheduled repositioning and patient resistance related to discomfort, fatigue, or limited understanding of the preventive purpose. These obstacles highlight the need for organizational and patient-centered solutions that address both workflow limitations and individual patient concerns.

A4c: Interventions

Targeted interventions can mitigate identified barriers and improve protocol adherence. The establishment of dedicated “turn teams” or designated staff responsible for repositioning enhances accountability and consistency. Additionally, engaging patients in discussions about their repositioning schedule empowers them to participate actively in their care. Providing education through verbal explanations, visual reminders, and bedside tools increases awareness of the benefits of repositioning and improves patient cooperation.

A4d: Shared Decision-Making

Successful implementation of pressure injury prevention protocols depends on collaborative decision-making among nurses, physicians, and wound care specialists. Shared goals related to skin integrity promote mutual accountability and streamline communication. Transitioning from a task-oriented approach to a team-based nursing model clarifies roles, reduces duplication of effort, and ensures continuity of care. This collaborative framework supports consistent intervention delivery and improved patient outcomes.

A4e: Outcome Measures

The effectiveness of the proposed intervention should be evaluated using both quantitative and qualitative measures. Key indicators include the incidence of new pressure injuries before and after protocol implementation and compliance rates with documented repositioning schedules within the electronic health record (EHR). Staff feedback regarding workflow challenges and protocol feasibility provides valuable insight for continuous quality improvement and long-term sustainability.

A4f: Care Delivery Model and Impact

Shifting to a team-based care delivery model offers a sustainable and coordinated approach to pressure injury prevention. Within this model, nurse managers monitor compliance and documentation accuracy, charge nurses oversee daily workflow coordination, and bedside nursing staff execute repositioning interventions and provide real-time feedback. This structured distribution of responsibilities strengthens interprofessional collaboration, enhances accountability, and improves communication across care teams. Ultimately, the model supports better patient outcomes, higher staff engagement, and improved institutional performance metrics.

Summary Table: Barriers and Interventions for Turning Schedule Implementation

References

Agency for Healthcare Research and Quality. (2017). Pressure injury prevention in hospitals training program. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/index.html

Khan, M., & Jonusas, E. (2019). Turn teams: How do you prevent pressure injuries? MEDSURG Nursing, 28(4), 257–261.

D221 Final Paper: Practice Improvement Plan for Pressure Injury Prevention

Tervo-Heikkinen, T., Heikkilä, A., Koivunen, M., Kortteisto, T., Peltokoski, J., Salmela, S., Sankelo, M., Ylitörmänen, T., & Junttila, K. (2023). A cross-sectional national study of nursing interventions in preventing pressure injuries in acute inpatient care. BMC Nursing, 22(1), 1–12. https://doi.org/10.1186/s12912-023-01369-8